Fellowship Story Showcase
Primary care may give way to specialization
Dr. Robert Trevino listens, nods and taps a stylus on a hand-held computer as his third patient of the day explains his dilemma.
A cardiologist recently urged 74-year-old John Galan, a diabetic, to take an aspirin to reduce his risk of stroke. But Galan has an ulcer and is worried about his stomach.
“The brain is more important,” Trevino tells him.
“I got to die of something anyway,” Galan sighs.
“Yeah, but not yet. I need the business.”
Trevino is fibbing. About 70 percent of his patients suffer from diabetes. He has plenty of business.
And they get pretty good care. His group of primary care doctors invested in an expensive medical record system that communicates with hospitals and pharmacies and is wirelessly connected to the tablet computer he carries. With the push of a button he can create a graph showing changes in his patients' weight, their hemoglobin A1c levels (which detect long-term blood sugar control), their blood pressure or LDL cholesterol.
But it's a constant, uphill battle. Weary of working hard to keep his diabetic patients healthy only to see their slow decline despite his best efforts, he turned part of his attention to research and prevention 13 years ago. He created the bilingual Bienestar diabetes prevention program, used in elementary and middle schools throughout South Texas to improve eating habits and fitness levels. But he bemoans the lack of money society spends on preventing illness.
“The medical model is not working,” Trevino said. “What do we pay for that — $13,000 a year to care for a diabetic? We pay $60,000 a year for a patient on dialysis, and we add 2,000 dialysis patients every year in the state of Texas.”
Family practice and internal medicine physicians make up the front lines of the war against diabetes. While endocrinologists and other specialists treat the disease, 80 percent of diabetics' office visits are with primary care doctors.
But almost everyone acknowledges the U.S. health care system isn't designed for chronic, lifelong diseases like diabetes. Reimbursement is heavily weighted toward procedures like surgery and catheterizations, rather than disease management. But chronic diseases now account for 70 percent of all deaths.
Which is one reason why primary care might be an endangered profession. A survey published this month in the Journal of the American Medical Association found that few medical students are leaning toward general internal medicine, in part because of the demands and low pay associated with chronic diseases.
Another survey of San Antonio primary care doctors a decade ago found that they had a fairly dour outlook on diabetes. Most found it a lot harder to treat than most other illnesses.
With a fine line to traverse between good blood sugar control and the dangerous risk of hypoglycemia or low blood sugar, they complained that medication is difficult and labor-intensive to adjust. They reported “horrible struggles” with patients over diet and exercise changes. The disease requires more coordination between patients and specialists, they said. And its symptoms are an unreliable guide to how sick the patient is.
Back in 2002, a researcher at Audie Murphy VA Hospital decided to study what really happens when diabetics and their doctors come together in the exam room. Whatever they discussed — whatever prescriptions were written or chest sounds heard or lab tests ordered — in the end, it just wasn't making that big a difference after the patient went home.
So the researcher, Dr. Michael Parchman, asked doctors in 20 private and government-run clinics to allow someone to stand in the corner and watch as a couple of hundred diabetic patients came in for routine office visits. And when the study was finished, the number 17 took on surprising significance.
“The average length of the visit for a person with diabetes is 17 minutes,” Parchman said. “In those 17 minutes, we found that 17 different topics or issues were discussed. I am not exaggerating. I can give you the decimal points if you want me to.”
Parchman, also a professor of family and community medicine at the University of Texas Health Science Center, was interested in why doctors aren't more aggressive in ratcheting up medicines when blood sugars are uncontrolled. One big reason is competing demands — that all of those symptoms compete for attention in a 17-minute visit against the real, potentially deadly problems in diabetes — high blood sugar, high blood pressure and cholesterol.
And the symptoms usually win. For patients with high A1c levels, each additional patient concern that came up was accompanied by a 49 percent drop in the odds that the doctor would make any change in medication.
“It's very difficult,” Parchman said. “Because my patients with diabetes don't just come to me with diabetes. They have emphysema; they have depression; they have a skin rash; they have a headache; they have toenail fungus. The list goes on and on.”
Doctors do have guidelines for treating diabetes. The American Diabetes Association publishes a set. So does the state of Texas through its Texas Diabetes Council.
And yet, in a report released this year by the council, it noted that a Texas study found that if doctors did everything they were supposed to do for their diabetic patients during a routine office visit, they would lose money at the current rate of reimbursement — a 6.1 percent deficit per year after expenses.
Cloning your doctor
“If your family doctor wants to do diabetes care, physical exams, educate his patients, answer the phones, answer the messages, write letters, do rounds in the hospital and see all his patients when they're sick for acute care and chronic care, you would need to clone your family doctor and make another family doctor exactly like him,” explained a very busy Dr. Ramon Reyes, who at midmorning is already running behind at his Northwest Side clinic.
And yet, by some accounts, Reyes does it better than most. He has trained and reorganized his office staff — including the receptionist — to interact with patients, to schedule lab and specialty appointments, to follow up and walk them through all that needs doing, including listening to their concerns. His nurses are trained as diabetes educators.
An electronic medical record allows him to identify and track his diabetic patients, including those whose A1c readings are too high. While conceding its value to his patients, he shakes his head at those experts who say the technology will save the health care system money.
“It doesn't save money. It doesn't make you more efficient. And I'm being honest here. What it does is it adds two minutes to every encounter a day. Now, rather than spend nine minutes with a patient, my encounter is 11 minutes,” Reyes said.
Still, with the information it can give him, he can easily identify patients as a group. He holds periodic diabetes fairs with invited speakers (“Do I get compensated for that? No,” he said), and invites those who are struggling to meet as a group with a diabetes educator.
And he knows that 66 percent of his diabetic patients are at goal for A1c levels, LDL cholesterol and blood pressure.
“It requires a lot of caring, a lot of listening, a lot of passion, a lot of being Don Quixote — because you have to do it on your own. The system doesn't ask you to do it, and they don't pay you to do it,” Reyes said.
Reyes' practice is organized fairly closely to the Chronic Care Model, a set of guidelines promoted by the Robert Wood Johnson Foundation and others on how to reorganize physician practices. A central tenet is that the patient's role is equally important as the doctor's — if not more so — when it comes to diabetes and other chronic conditions.
“The approach back then was, you give them information and you hope for the best. And we know that information is not enough now,” said the model's architect, Dr. Ed Wagner, director of the MacColl Institute for Healthcare Innovation at the Group Health Cooperative of Puget Sound in Seattle.
“If you want to help patients become competent managers of their diabetes, you've got to help them through it,” Wagner said. “It's support, it's setting goals, it's helping them overcome barriers. And it's an ongoing process. And we found that most practices have no idea how to do this.”
One study, conducted by Parchman, found that diabetic patients whose doctors ran their practices closest to the chronic care model had the lowest risk of heart attack and stroke, based on blood sugar levels, blood pressure and cholesterol. Other studies have come up with similar findings.
“There's good evidence you don't need to lose 30 pounds to have a significant improvement in your hemoglobin A1c control,” Wagner said. “A relatively small percentage weight loss can do it. So you change the goals. And the doctor doesn't set the goals; they're set collaboratively. And that makes all the difference in the world, because when they patient is involved in establishing the goal, they have a greater stake in reaching it.”
Three stories on the challenges of managing diabetes appearing this week in the San Antonio Express-News were reported with the assistance of the USC Annenberg/California Endowment Health Journalism Fellowships, administered by the USC Annenberg School for Communication. The Express-News and KWEX-TV were selected by the program this year to report on diabetes and obesity, with a particular focus on the impact on Hispanic communities